A Comparative Open Labeled
Clinical Study to Evaluate the
Efficacy and Tolerability of Two
Different Intravaginal Formulations
Containing a Combination of
Clindamycin and Clotrimazole in
Patients of Bacterial, Trichomonal,
Candidial and Mixed Vaginal
Infections
Principal Investigator:
Dr. Bharti R. Daswani
Co-Investigators:
Dr. PW Sambarey
Dr. BB Ghongane
Dr. Renu Bhardwaj
Dr. Shilpa Naik
Dr. Meghana Palewar
INTRODUCTION AND BACKGROUND KNOWLEDGE:
Vaginal discharge and associated vulval itching are the most common reasons for a
woman to seek gynecological care.
It is estimated that approximately 80% of non-pregnancy, non-routine visits to a
gynaecologist are prompted by the presence of a vaginal discharge.
Infections are involved in more than 90% of the cases coming to observation for vaginal
irritation and discharge. Other, less frequent causes may be mechanical, chemical, or
allergic reactions (e.g., to latex).
Furthermore, treatment success rates as low as 52% and recurrence rates 50% within
6-12 months are common.
Thus, vaginal infections represent a relatively benign disease that is associated with
frequent recurrence and huge healthcare costs. Furthermore they are associated with
Gynecologic complications like increased risk of HIV, recurrent cystitis, PID [including
post-abortion and subclinical PID],cervicitis, postsurgical gynecologic infections and
obstetric complications like early spontaneous abortion , preterm labor, premature
rupture of membranes. Chorioamnionitis, higher risk of low-birth-weight infants,
postpartum endometritis.
Hence, a timely diagnosis followed by appropriate treatment may well be more than
cost-effective
CAUSATIVE ORGANISMS: Trichomonas vaginalis, a protozoan and a fungus,
Candida albicans, are the micro-organisms frequently involved as causative agents,
while bacterial vaginosis is a polymicrobial infection associated with dramatic increases
in anaerobic bacteria (Prevotella spp, Peptostreptococcus spp, Mobiluncus spp,
Bacteroides spp, Eubacterium spp) and facultative bacteria (Gardnerella vaginalis,
Mycoplasma hominis, enterococcus, and group B streptococcus). Mixed infections are
believed to occur in approximately 25% of cases.
Thus, the presenting symptoms may be similar, but different micro-organisms may be
responsible for the infection. Hence, there are different therapeutic strategies that need
to be adopted.
Current Treatment Recommendations
Bacterial Vaginosis
Metronidazole 500mg PO bid for 7 days
Clindamycin 300mg PO bid for 7 days
Metronidazole gel 0.75% bid per vagina for 5 days
Clindamycin cream 2% per vagina for 7 nights
Trichomonas
Metronidazole 2g PO, single dose
Metronidazole 500mg PO for 7 days
Clotrimazole single 500mg tablet or cream used once intravaginally at night, or
200mg suppository inserted intravaginally once daily at bedtime for 3
consecutive days or 100mg suppository inserted intravaginally once daily at
bedtime for 6-7 consecutive days
Candida
Intravaginal imidazoles and triazoles like
Clotrimazole given as single 500mg tablet intravaginally at bed time or as 200mg
tablet inserted intravaginally once daily at bedtime for 3 consecutive days)
or 1% cream/ 100mg tablet used once intravaginally at night for 7 days
Fluconazole 150mg PO single dose [weekly for up to 12 consecutive weeks for
recurrent infections]
Boric acid 600mg gelatin capsule per vagina bid for 10 days
Thus, appropriate treatment is based on diagnosis by routine staining methods, culture
and sensitivity reports and molecular probes available. However, sensitivity of the
routine methods is questionable as it is not 100% and if one selects molecular probes,
the most accurate method for diagnosis, high costs and the expertise needed to run
them routinely are a problem.
Therefore there is a need of treatment that covers all the common pathogens
associated with vaginal infections.
Clotrimazole is an imidazole anti-fungal agent with broad spectrum action. It brings
about its therapeutic effect by inhibiting ergosterol synthesis. Inhibition of ergosterol
synthesis alters the permeability of the cell membrane of sensitive fungi and leads to
structural and functional impairment of the cytoplasmic membrane. It is active against
trichomonas and candida.
Clindamycin is an antibacterial that acts against both aerobic and anaerobic bacteria.
It is a derivative of the amino acid trans-L-4-n-propylhygrinic acid, attached to a sulphur
containing derivative of an octase. It is congener of lincomycin. Clindamycin binds
exclusively to the 50S subunit of bacterial ribosomes and suppresses protein synthesis.
Thus, together clindamycin and clotrimazole act against candida, trichomonas and
bacteria involved in the pathogenesis of vaginitis.
Hence, an intravaginal formulation that contains clindamycin and clotrimazole may be
suitable for most cases of bacterial, trichomonal, candidial as well as mixed vaginitis.
Two different intravaginal formulations of such a combination of clindamycin and
clotrimazole are available. One is a soft gelatin vaginal capsule that releases the drugs
immediately, while the other is an extended release vaginal tablet containing
clindamycin and clotrimazole as a novel mucoadhesive vaginal drug delivery system
that swells in the presence of vaginal fluid to form a spongy, soft mass that adheres to
the vaginal mucosa and releases the drugs over a period of 4-8hours. This novel
design is claimed to overcome the drawbacks of conventional vaginal preparations such
as unpredictable drug delivery, low residence time, leakage of liquid and messiness.
Thus, the novel extended release tablet may provide sustained drug delivery giving
greater effectiveness complemented with less side effects and less discomfort due to
formation of non-abrasive, spongy, soft mass.
AIMS AND OBJECTIVES:
To compare the effectiveness of 3 day treatment with intravaginal soft gelatin capsule
of clindamycin and clotrimazole versus intravaginal extended release [ER] tablets of
clindamycin and clotrimazole in patients of bacterial, trichomonal, candidial or mixed
vaginitis with respect to clinical manifestations
To evaluate the effectiveness of 3 day treatment with intravaginal soft gelatin capsule
of clindamycin and clotrimazole versus intravaginal ER tablets of clindamycin and
clotrimazole in patients of bacterial, trichomonal, candidial or mixed vaginitis with
respect to microbiological findings
To assess the tolerability of 3 day treatment with intravaginal soft gelatin capsule of
clindamycin and clotrimazole versus intravaginal ER tablets of clindamycin and
clotrimazole in patients of bacterial, trichomonal, candidial or mixed vaginitis
To study the in vitro drug release pattern of intravaginal soft gelatin capsule and
intravaginal ER tablets containing clindamycin and clotrimazole by HPLC analysis
Primary Endpoint:
Effectiveness of 3 day treatment with the combination of clindamycin and clotrimazole
in inducing remission in patients with vaginal discharge and clinical diagnosis of
bacterial, trichomonal, candidial, mixed vaginitis.
Secondary End points:
Effectiveness of 3 day treatment with the combination of clindamycin and clotrimazole
in maintaining remission in patients with vaginal discharge and clinical diagnosis of
bacterial, trichomonal, candidial, mixed vaginitis.
Tolerability of the 3 day treatment with the combination of clindamycin and clotrimazole
in patients with vaginal discharge and clinical diagnosis of bacterial, trichomonal,
candidial, mixed vaginitis.
SUBJECTS AND METHODS:
STUDY DESIGN:
This is a Randomized, Comparative, Prospective, Open label, single center study of
efficacy and tolerability of two different intravaginal formulations containing a
combination of clindamycin and clotrimazole in patients with vaginal discharge and
clinical diagnosis of infective vaginitis [bacterial, trichomonal, candidial, mixed].
The study will be conducted by the Department of Gynaecology & Obstetrics,
Department of Pharmacology, Department of Microbiology in, B.J. Medical College, and
Sassoon General Hospitals, Pune. The study will be completed in 60 patients [30
patients in each group].
STUDY POPULATION:
Inclusion Criteria:
Women with symptoms of vaginal discharge and/or odor and a clinical diagnosis of
vaginitis of infective origin [based on symptoms and signs on per speculum
examination]
Age at least 18 years
Capable of giving written informed consent
Agree to no intercourse for 8 days from the day of start of treatment
Agree not to douche or use any intravaginal products during the study period (including
tampons, medications and devices)
Exclusion Criteria:
Post-menopausal women
Menstruating at diagnosis
Pregnancy
Any antifungal or antibiotic use 14 days prior to enrolment
Use of oral or intravaginal antibiotics within the past 2 weeks
Immunosuppressive drug within 4 months
Presence of vaginal / vulval ulcer
Presence of any other vulval, vaginal or medical condition, including cervical neoplasia/
treatment that might confound treatment response
Inability to keep return appointments
History of hypersensitivity to clotrimazole, clindamycin or lincomycin
History of regional enteritis, ulcerative colitis or ‘antibiotic associated’ colitis
Significant disease or acute illness that in the Investigator's assessment could
complicate the evaluation
Intrauterine Device
During the initial visit, the gynaecologist will take a history. After a speculum and
manual pelvic examination the findings will be noted. Cases with vaginal discharge and
clinical diagnosis of vaginitis of infective origin [bacterial, trichomonal, candidial, mixed]
on the basis of symptoms and per speculum examination will be informed about the
study, and will be given a handout explaining the study. If the woman is interested in
participating, she will be given a consent form to sign. Subsequently 1 swab will be
obtained from high in the vagina for microbiological investigation. Per vaginal discharge
will also be collected on microscopy slides for Whiff test and assessing its pH.
Whiff test will be performed by adding a small amount of10% potassium hydroxide to a
microscopic slide containing the vaginal discharge.
pH of the discharge will be checked using a pH paper. A pH greater than 4.5 will be
considered as alkaline.
The swab will be sent to the microbiology laboratory for microbiological diagnosis using
1)
Wet mount [for presence of Trichomonas vaginalis and clue cells [epithelial cells
that are coated with bacteria];
2)
Quantification by culture on Sabourands medium [for Candida albicans]; and
3)
Gram’s stain of smear [for Bacterial vaginosis]: The smear will be scored from
Grade 1 - 3 by Hay/Ison criteria as follows:
Grade 1 (Normal): Lactobacillus morphotypes predominate.
Grade 2 (Intermediate): Mixed flora with some Lactobacilli present, but Gardnerella or
Mobiluncus morphotypes also present.
Grade 3 (Bacterial Vaginosis): Predominantly Gardnerella and/or Mobiluncus
morphotypes. Few or absent Lactobacilli. (Hay et al., 1994)
Drug Administration:
After baseline examination and swab collection, the eligible subjects will be randomized
into 2 groups. Subjects belonging to Group A will receive intravaginal soft gelatin
capsule of clindamycin and clotrimazole combination while subjects belonging to Group
B will receive intravaginal extended release [ER] tablets of clindamycin and clotrimazole
combination.
The first dose will be inserted by the gynaecologist as deep into the vagina as possible.
The patient will be trained for insertion of the intravaginal formulation with hands
thoroughly washed before insertion. This will be considered as Day 1 of the study. The
procedure will be repeated by the patient for 2 consecutive days [Day 2 and Day 3 of
the study].The patient will be asked to refrain from any activity such as standing,
walking, running etc. for at least 4 hours after insertion of either of the 2 intravaginal
formulations, and abstain from sexual intercourse for 8 days following initiation of drug
administration [i.e.Day1 to Day 8].
Follow-up:
The patients will be reassessed once on the 8th day after start of the 3 day course of
drug administration [follow-up visit 1] for evaluating the success of treatment and again
on the 29th day after the start of drug therapy [follow-up visit 2] for studying recurrence.
A flexibility of + or - 7 days will be permissible for the second follow-up visit in case the
patient is unable to report for follow up on the 29th day after the start of drug therapy.
At each of these visits the patient will be enquired for presence or absence of symptoms
of vaginitis. She will undergo per speculum examination and findings will be noted.
Again 1 swab will be obtained from high in the vagina for microbiological examination
and vaginal discharge will be collected on microscopy slides for whiff test and pH
assessment as above.
At each visit, the patients will also be asked to fill in details of the subjective evaluation
head of the Case Record Form which includes questions related to vaginal discharge,
itching and tolerability of the test formulation (side-effect profile) [Vide Case Record
Form: Section on “Subjects’ assessment of the test formulation” ].
Primary Outcome Measures:
Effectiveness at 8th day after start of treatment.
If the woman has no sign suggestive of infective vaginitis and vaginal swab is negative
for bacterial, trichomonal or candidial vaginitis at 8th day after start of treatment, this will
be considered a treatment success addressing our primary endpoint for effectiveness.
However, if at the 8th day after initiation of treatment, the vaginal swab is still positive for
bacterial, trichomonal or candidial vaginitis irrespective of presence or absence of signs
and symptoms, this will be considered a treatment failure addressing our primary
endpoint for effectiveness.
Secondary Outcome Measures:
Effectiveness at 29th day after start of treatment.
If at the 29th day after initiation of treatment, the patient does not have any signs
suggestive of infective vaginitis and vaginal swab is negative for bacterial, trichomonal
or candidial vaginitis, this will be considered a treatment success addressing our
secondary endpoint for effectiveness at 29th day of the study.
However, if at the 29th day after initiation of treatment, the vaginal swab is positive for
bacterial, trichomonal or candidial vaginitis irrespective of presence or absence of signs
and symptoms despite treatment success at the 8th day after start of treatment, this will
be considered a treatment failure addressing our secondary endpoint for effectiveness.
Tolerability
If the patient completed the 3 day course without any break and did not experience
intolerable side effects, this will be considered as treatment success referring to our
secondary endpoint for tolerability.
However, if the patient discontinued the treatment during the 3 days because of side
effects or complained of intolerable side effects from the treatment this will be
considered as treatment failure addressing our secondary endpoint for tolerability.
Study of in vitro release pattern of Clindamycin and Clotrimazole by HPLC
analysis:
Vaginal simulate fluid medium will be prepared by adding NaCl, 3.51g; KOH, 1.40g;
Ca(OH)2, 0.222g; bovine serum albumin, 0.018g; lactic acid, 2.00g; acetic acid, 1.00g;
glycerol, 0.16g; urea, 0.4g; glucose, 5.0g to sufficient quantity of distilled water to make
1 litre. This simulant has the physical and chemical properties such as pH [pH 4.2] and
osmolarity similar to those known to govern drug release and distribution from per
vaginal route.
1 tablet of either of the formulations will be placed in 100 mL of vaginal simulate fluid
medium providing sink conditions. The medium will be maintained at 37ºC and stirred at
100 rpm.
1 mL of dissolution fluid will be collected at 0.5,1,2,3,4,6,8,10,12 and 24 hours. The
medium will be replaced with an equal volume of vaginal simulate fluid equilibrated to
temperature. Levels of clindamycin and clotrimazole in the samples will be analyzed
using HPLC, Release of the drug will be expressed as percentage of total drug present
in each tablet. The procedure will be repeated for 6 soft gelatin capsules and
6extended release [ER] tablets.
STATISTICAL ANALYSIS:
The results will be analyzed on per-protocol basis.
Number of patients achieving primary end-point for effectiveness at 8th day after start of
treatment in both the groups will be analyzed using Chi-square test.
Number of the patients achieving secondary end-point for effectiveness at 29th day of
the study in both the groups will be analyzed using Chi-square test.
Number of the patients achieving secondary end-point for tolerability in both the groups
will be analyzed using Chi-square test.
Number of the patients showing reduction in vaginal pH to 4.5 at second and third visit
in both the groups will be analyzed using Chi-square test.
Number of the patients achieving improvement in scores for quantity of vaginal
discharge and itching by at least 1 unit from first to second [Measure of Treatment] and
first to third visit [Measure of Recurrence] in both the groups will be analyzed using Chisquare test.
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